Physical Therapy Intake Form

Physical Therapy Intake Form — Form Fields

This healthcare template includes 9 fields across 2 pages. Gather patient details, injury history, and goals for physical therapy treatment. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Date of Birth (text, required)
• Phone Number (text, required)
• Referring Physician (text, optional)
• Primary Area of Concern (dropdown selection, required) — options: Neck / Cervical, Shoulder, Back / Spine, Hip, Knee, Ankle / Foot, Wrist / Hand, Other
• Describe your injury or condition (long text, required)
• Have you had surgery for this condition? (multiple choice, required) — options: Yes, No
• Goals for Physical Therapy (long text, required)
• Patient Signature (signature, required)